MEDICARE: LAKIFFANIE PATRYCE JACKSON APRN-CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QX0200X	Oncology Clinic/Center	754934	TX
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1134383	TX

General Provider Information

NPI Number	:	1881464246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKIFFANIE PATRYCE JACKSON APRN-CNP

Provider Business Mailing Address
First Line	:	2006 VERMILLION OAK ST
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-2050
Country	:	US
Telephone Number	:	713-315-1048
Fax Number	:

Provider Business Practice Location Address
First Line	:	7070 KNIGHTS CT STE 1301
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-5525
Country	:	US
Telephone Number	:	713-352-3166
Fax Number	:	713-547-4468

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2024
Last Update Date	:	04/10/2024

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